February 2008




Veteran perspective: learning to thrive in an inclement healthcare climate

by Richard L. Lindstrom, M.D.


Richard L. Lindstrom, M.D., current president of the American Society of Cataract and Refractive Surgery (ASCRS), is perhaps the most talented individual I have ever met in my life. He has been a leader in both cataract and refractive surgery, as well as president of both the International Society for Refractive Surgery (ISRS) and the International Intraocular Implant Club (IIIC). He is also an extremely astute business man with impeccable integrity. He has a unique way of looking at the economics of ophthalmic practice, which over the past decade and a half has become of increasing concern to ophthalmologists. During that time, expenses have gone up by over 40% and reimbursement has gone down approximately 70%. I think all ophthalmic surgeons will enjoy, learn from, and hopefully benefit from Dick Lindstrom’s current view of the landscape within which we practice.

I. Howard Fine, MD, Column Editor


Economic forces having many ophthalmologists looking for cover

A gale of economic factors … from diminishing Medicare rates to increasing competition for patients … have put a strain on the livelihood of many ophthalmologists. When I was first starting out we had the attitude that succeeding was just a matter of hard work. If you put the time in and followed the correct steps then your practice would blossom accordingly. Unfortunately, that isn’t necessarily the case today, even for those who have been in practice for some time. We are currently under attack from a number of fronts. Yet, may of us are still finding a way to succeed.

Unfavorable trade winds One of the difficulties today is that we’re facing more competition than we did in the past. Currently there are almost two optometrists (36-38,000) for every ophthalmologist (18-19,000). However, figures from a recent Rand study suggest that there are overall 38% too many eye-care practitioners. While of course optometrists cannot perform all of the same functions as ophthalmologists, there is considerable overlap in the areas of excessive refractive expense and medical eyecare. This seeming excess of “eye-care practitioners” will directly impact demand of ophthalmologists and therefore, available slots at medical schools and residency programs. Will this “excess of eye care practitioners” disappear over the next decade as the aging 78,000,000 Baby Boomers turn 65 and increase their demand for eye care services? The ophthalmologist of today must survive until the increased demand materializes. The fact is that most of the baby boomers who were interested in undergoing refractive surgery such as LASIK, have done so already. Those who have not yet had the procedure are likely not going to roll through the doors until it is possible to treat presbyopia as well. The next great ophthalmic movement from this generation will likely come down the road via refractive cataract surgery or presbyopia treatment with corneal inlays or refractive lens exchange. Will the future of anterior segment surgery repeat with Generation Y?

What role does the government really play?

Meanwhile healthcare dollars are tightening. The government generally doles out the largest amount of medical dollars to hospitals, followed by doctors, then on medication, and lastly to nursing homes. Unfortunately, they tend to cut down on their spending in that order. Here in Minnesota alone, over a ten year period, 12 major hospitals have gone bankrupt as they faced reductions in reimbursements stemming from introduction of diagnosis related groups. We doctors have also felt the squeeze, with the government offering up considerably less reimbursement for long-time bread and butter procedures such as cataract surgery. Today we are now receiving less than 1/3 the reimbursement for routine cataract surgery back in 1980. The cost of living of course has gone up exponentially since then. In terms of the same cost of living, I often use the “cataracts per Cadillac ratio” ... Today, ten times as many cataract surgeries are needed to buy a Cadillac compared to 10 years ago.

Many practitioners are feeling the pinch. For the past 25 years we have seen continued cuts in procedural rates and there is potentially no end to this unless Medicare is significantly reformed. Until the day when patients find they can no longer find practitioners who are willing to perform the procedure for such low rates, Medicare will undoubtedly continue to decrease fees. Having spent years in school and residency training, this is quite disheartening for the future of ophthalmology and medicine as a whole and will inevitably impact the future of health care as a chosen profession. Perhaps it will take this dramatic reduction in available healthcare to illustrate the impact of continued government intervention.

At first glance it may be tempting to believe the government will initiate healthcare reform as many do. Ultimately, this is not in the best interest of ophthalmologists. The last thing ophthalmologists need is additional stipulations about ocular procedures. Elective procedures such as refractive surgery and prebyopa-correcting IOLs are currently at the discretion of the consumer and should remain so. It is up to the public to decide whether they want to spend their discretionary income on procedures such as LASIK or refractive lens exchange and how much such procedures are worth to them. We do not need the government to come in and set the rates. It is in the best of interest of all involved that healthcare providers work closely with the patients they serve in order to truly achieve optimized health care system, which demands a change to deferred contribution plans along with patient shared responsibility for costs.

Clearer horizons

With all of this unrest swirling about it’s no wonder why many ophthalmologists are feeling the pressure. However, it is possible to safeguard your business. The key is in building solid relationships with your patients. This means providing premium care despite prices that may appear to be “discounted.” If practitioners ensure that their patients are provided with top-notch care from their first preoperative call to their last follow-up visit, this will ensure not only patient loyalty, but also important word-of-mouth referrals.

We need to strive to give our educated potential patient population their due by helping them preserve, restore, and enhance their vision. This will only be achieved by investing time to answer their questions and to reassure patients about the elective procedures that they have selected, inevitably focusing on customer service.

Going forward I believe that much of our success will be linked to this new, educated group of patients who are willing and able to pay market rates for the elective, lifestyle-enhancing procedures they want. We must learn to incorporate their business as well as the patients who cannot afford these elective procedures into our practices to help them continue to prosper. This paired with an open dialogue between healthcare providers and the public about achieving optimized health care for all will ultimately serve to make the difference in our future, thereby allowing us to serve our patinets best.

Veteran perspective: learning to thrive in an inclement healthcare climate Veteran perspective: learning to thrive in an inclement healthcare climate
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